A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
Taking the infant's vital signs every 2 hr
Counting the number of wet diapers every shift
Weighing the infant at the same time every day
Measuring the infant's head circumference twice per day
The Correct Answer is C
A. Taking the infant's vital signs every 2 hr: Monitoring vital signs every 2 hours can help assess the infant’s general condition and detect changes in heart rate and blood pressure, which can indicate changes in hydration status. However, it might not be sufficient alone to monitor fluid status.
B. Counting the number of wet diapers every shift: Tracking the number of wet diapers is an effective way to monitor the infant's fluid output and hydration status. An increase in wet diapers typically indicates improved hydration. This is a practical and non-invasive method for assessing the effectiveness of IV therapy in infants.
C. Weighing the infant at the same time every day: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant’s hydration status and response to IV therapy.
D. Measuring the infant's head circumference twice per day: Measuring head circumference is not relevant for monitoring hydration status. It is typically used to assess growth and development in infants, not fluid balance or response to IV therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Keep the client's leg in a dependent position. Keeping the leg in a dependent position can increase swelling and delay healing. The leg should be elevated to reduce swelling and promote circulation.
B. Use a hair dryer on a hot setting to dry the cast. Using a hair dryer on a hot setting can cause burns and does not effectively dry a plaster cast. Plaster casts take time to dry and should be air-dried naturally.
C. Discourage the client from ambulating: Early mobilization is encouraged to prevent complications like muscle atrophy and joint stiffness, as long as it is safe and the healthcare provider has approved it. Completely discouraging ambulation is not generally recommended unless specified by a doctor.
D. Perform a neurovascular check of the lower extremities. Neurovascular checks are essential to ensure that there is adequate blood flow and nerve function below the cast. This includes checking for pain, pallor, pulse, paresthesia, and paralysis (the 5 P’s). This helps detect complications like compartment syndrome or decreased circulation early.
Correct Answer is C
Explanation
A. "Your newborn will receive the first DTaP vaccine during the initial well-baby visit.": The first dose of DTaP is typically given at 2 months, not at the newborn stage.
B. "Your newborn should receive an immunization for MMR at 6 months.": The MMR vaccine is usually administered at 12-15 months, not at 6 months.
C. "Your newborn is scheduled to have a hepatitis B vaccine prior to discharge.": Hepatitis B vaccine is recommended to be given within 24 hours of birth as the first dose of a series.
D. "Your newborn should receive the PCV vaccine two times prior to his first birthday.": The pneumococcal conjugate vaccine (PCV) schedule starts at 2 months with multiple doses, but not specifically "two times" before the first birthday.
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